Application form. Dental Care Professionals and Practice Managers

Transcription

1 Application form Dental Care Professionals and Practice Managers

2 2 Dental Care Professionals and Practice Managers Please print your answers clearly, using a black or blue pen. Please complete all sections of this form, read the declaration and agreement on page 10 and sign the statement at the bottom of page 3. Incomplete or unsigned forms cannot be processed and will be returned. If you require any help completing this form please contact us. Call our freephone membership helpline: Lines are open 8am to 6pm, Mon-Fri (except bank holidays). or Visit our website theddu.com/liaison for details of your local DDU liaison manager. Before returning this form to us check you have: completed each relevant section completed your payment choice signed the statement on page 3 3 Return the completed form to: FREEPOST MDU SERVICES LIMITED.

3 Dental Care Professionals and Practice Managers 3 A Personal details Please write in CAPITALS Date of birth D D M M Former DDU number (if applicable) Title Surname Forenames Previous surname (if applicable) Gender M F Home address Work address Organisation: Address: Please tick to send correspondence to this address Please tick to send correspondence to this address Preferred (Please tick home or work) H W Secondary (Please tick home or work) H W Contact number(s) Mobile Alternative (Please tick home or work) H W B Academic details Please write in CAPITALS Country of graduation Dental school/college/university Qualification obtained Graduation date D D M M C Previous professional indemnity provider Please write in CAPITALS Please provide details of all your professional indemnity/insurance providers since qualification. All dates should be accounted for, including periods when you were not working (e.g. parental leave) or had indemnity provided by your employer (e.g. indemnity from HS bodies) or indemnity was not required in the country you were working in. Start date End date Indemnifier name (and address if not UK) or reason for gap Registration no / Membership no D Registration details Please write in CAPITALS GDC registration number Registration type eg. Dental hygienist, dentist, dental nurse Registration status Full Temporary Statement: Please complete the form and sign below I confirm that the information provided within this form is complete and an accurate representation of my practice. I consent to all use and processing of my personal data in accordance with the terms of the DDU s privacy policy. I agree to receive notices, documents and other information from the DDU by electronic communication unless I have indicated otherwise on page 11. I authorise and request my current and any former dental defence organisation, insurance company or indemnity provider to release to MDU Services Ltd information regarding my membership or my insurance or indemnity contract, complaints of a dento-legal nature, claims or actions for damages or compensation, past or present, during my period of membership and/or indemnity, whether or not there has been a final resolution, and I consent to the disclosure of such information to the DDU. The Dental Defence Union (DDU) is the specialist dental division of The Medical Defence Union Limited (MDU) and references to the DDU and DDU membership mean the MDU and membership of the MDU. Office use only Signature Date D D M M

4 4 Dental Care Professionals and Practice Managers E General questions Please tick relevant answer Please read questions E1 to E11 carefully. Any misrepresentation or omission of information may lead to the rejection of your application, subsequent termination of membership or withdrawal or denial of benefits. If in doubt, tick yes If you answer yes to any question, please provide details on page 5 including: question number relevant dates the nature of the matter in question how the matter was resolved whether you were assisted by an insurer, medical defence organisation or other body E1 Are you aware of any incidents or circumstances involving you, irrespective of their seriousness, which could lead to an investigation, complaint, claim, disciplinary action, legal dispute, suspension from practice, imposition of restrictions or conditions on your registration or licence to practise, or your removal from a professional register or of your licence to practise, by a registration body? E2 Have you, in the last 10 years, had any complaints or claims brought or threatened against you, irrespective of their merits or seriousness? E3 Have any concerns ever been raised about your conduct, clinical practice or performance, educational progress, business administration or probity by an employer, dental school, HS trust, clinical colleague or any other body? (e.g. the Care Quality Commission or a private hospital) E4 Have you ever been the subject of an investigation or action under a disciplinary process or the HS Performers List Regulations, irrespective of the merits or seriousness of the matter that led to this? E5 Have you ever been suspended or dismissed from a post or had practice privileges or hospital admitting rights withdrawn, suspended or made subject to restrictions or conditions? E6 Have you ever been the subject of an investigation or an adverse finding by a registration or licensing body? (e.g. GDC/GMC) or any other body, e.g. the ational Clinical Assessment Service or a Royal College E7 Have you ever had restrictions or conditions imposed on your registration or licence to practise, or been removed, refused or erased from registration or had a licence to practise withdrawn or refused, by a registration or licensing body? E8 Have you ever been charged with, or convicted of, a criminal offence, or received a formal Police Caution? (Including any motoring offence even if you were fined but not imprisoned but excluding fixed penalty notices for speeding offences or parking tickets. ou should not disclose any cautions or convictions which are protected under the 2013 amendment to the Rehabilitation of Offenders Act 1974 Exceptions Order 1975) E9 Has any professional indemnity insurer or medical defence organisation ever declined to indemnify you, required special terms to indemnify you, cancelled or refused to renew your policy or membership or charged you an additional premium/subscription? E10 Have you ever been bankrupt or subject to insolvency proceedings, or entered into or proposed any voluntary arrangement with creditors? E11 Are there any other facts or circumstances that may be relevant to our considering your application? If so, please provide details.

5 Dental Care Professionals and Practice Managers 5 Additional information for section E Question number Please continue on a separate sheet if necessary.

6 6 Dental Care Professionals and Practice Managers F Work circumstances Please note your subscription will be based on the average number of sessions you work in a week. A session is each 4 hours or part of 4 hours worked. To calculate your average weekly sessions take the average number of hours you work per year, divide it by 52 and then divide by 4. The DDU does not currently provide indemnity to dental care professionals carrying out botulinum toxin and collagen replacement therapy, and all similar cosmetic procedures. F1 Please tick the type of work you undertake and indicate the number of sessions worked per week, where required. ou may tick more than one option. Practice owner A Practice owner is defined by the DDU as a person who does any of the following: Employs any staff who work in a dental practice. Commissions clinical services to be provided in a practice by other GDC registered dental professionals. Owns or runs a dental practice or a clinical facility, either as a sole practitioner or with others. A Dental Director of a Dental Body Corporate, or a partner in a limited liability or other dental practice partnership, including expense sharing partnerships. Registered provider with the CQC. An independent contractor provider of HS General Dental Services to a Primary Care Commissioning body or Health Board (does not include dentists employed directly by the Primary Care Commissioning body or Health Board). Practice manager Dental nurse Dental technician Orthodontic therapist Clinical dental technician Sessions per week Sessions per week Do you undertake Implant Retained Dentures? Dental hygienist and/or therapist If you have ticked dental hygienist/therapist, please complete the following: Are you indemnified by your employer? If no, do you want access to indemnity from the DDU? If yes, for how many sessions per week Dental hygienist Sessions per week Dental therapist Sessions per week Do you undertake tooth bleaching? If yes, please provide details of any training undertaken F2 Do you perform any of the following? E-consultations Giving advice over the internet Online prescribing (i.e. prescribing over the internet) Other telehealth work If yes, to any of the above, do you require access to indemnity from the DDU? If yes, please give full details, making sure to include the location of the patients (country), whether you are prescribing, any website address linked with this work (if relevant) and how may hours/patients per week.

7 Dental Care Professionals and Practice Managers 7 F3 Do you have any other clinical work for which you require access to indemnity? If yes, please provide full details continuing in the space below, if necessary. F4 Do you do anything which is not classified as normal for your specialty/group, for which you require access to indemnity and about which you have not already told us? If yes, please provide full details continuing in the space below, if necessary. F5 Do you work in any of the following regions? o es, all of my work es, some of my work Jersey Guernsey Isle of Man Scotland F6 Do you do any work outside of the UK? (Including the Republic of Ireland) If yes, do you require access to indemnity from the DDU? If yes, please phone the membership team to discuss your work. G Why have you chosen to apply for DDU membership? Please tick all that apply Subscription rates Personal recommendation Dissatisfaction with previous indemnity provider Dental Advantage Please provide your Dental Advantage number Other (please give details in space provided) H I Services text alerts We can send important text alerts to your mobile phone provided you have given us your mobile number on page 3. Please indicate below if you would like to opt in to text alerts. ou can stop text alerts at any time in the My membership section of our website. otification regarding your DDU renewal Additional information for section F Question number

8 8 Dental Care Professionals and Practice Managers J Paying your subscription our prospective membership will commence from the date that your completed application form is received by our membership department unless you specify a start date after this. This does not constitute acceptance of your membership, however, we will notify you if and when this is successful. Should you require your prospective membership to commence from today, please complete the Get a quote form at theddu.com/quote, or call the freephone membership helpline on Lines are open Mon to Fri, 8am to 6pm (except bank holidays). Date membership to commence: Immediately: Future date: D D M M Please be aware that subject to the information you provide and the date you submit your application, your subscription rate may change. If this is the case you will be informed prior to being accepted into membership. Please note that processing of your payment does not constitute acceptance of your application for membership. our payment will be refunded if your application is not successful. For your peace of mind we recommend you pay by Direct Debit and we have two options for your convenience. We can debit your account the full amount each year (see section K), or you can pay in monthly instalments by way of an agreement provided by Premium Credit Limited (see section L). ou only need to fill in the relevant mandate once and it will roll over from year to year. ou are protected by the Direct Debit safeguards and can cancel your authority at any time by contacting your bank or building society. For annual Direct Debit (single annual payment of full amount) please complete section K. For other payment options see sections L and M overleaf. K Annual Direct Debit payment option (Single annual payment of full amount) Annual Direct Debit mandate. Instructions to your bank/building society to pay by Direct Debit: Please complete parts K1-K4 to make payments directly from your account K1 Full name and postal address of bank/building society - including postcode: Postcode (required): K2 K3 ame of the account holder Bank/building society account number: Bank/building society sort code: Originator s identification number: K4 our instruction to the bank/building society and signature: I instruct you to pay Direct Debits from my account at the request of MDU Services Limited The amounts are variable and may be debited on various dates I understand that MDU Services Limited may change the amounts and dates only after giving me prior notice I will inform the bank/building society in writing if I wish to cancel this instruction I understand that if any Direct Debit is paid which breaks the terms of the instructions, the bank/building society will make a refund Signature Date D D M M Direct Debit Guarantee This guarantee is offered by all banks and building societies that accept instructions to pay Direct Debits. If there are any changes to the amount, date or frequency of your Direct Debit MDU Services Limited will notify you 5 working days in advance of your account being debited or as otherwise agreed. If you request MDU Services Limited to collect a payment, confirmation of the amount and date will be given to you at the time of the request. If an error is made in the payment of your Direct Debit, by MDU Services Limited or your bank or building society, you are entitled to a full and immediate refund of the amount paid from your bank or building society. - If you receive a refund you are not entitled to, you must pay it back when MDU Services Limited asks you to. ou can cancel a Direct Debit at any time by simply contacting your bank or building society. Written confirmation may be required. Please also notify us.

9 Dental Care Professionals and Practice Managers 9 L Monthly payments option (available for subscriptions over 50) Monthly instalments (no immediate payment is required). Have you incurred more than three CCJs against you within the last two years that have not been satisfied? Please choose an alternative payment option We will contact you once your application has been processed to set this up Please note that if you choose to pay by monthly instalments, Premium Credit Limited may apply a small interest charge. Details will be provided to you prior to any monies being taken. Payment will be taken over 10 months. Please do not complete the annual Direct Debit mandate as this only applies to single annual payment of the full amount M Alternative payment options Cheque. Please enclose a cheque made payable to MDU Services Ltd. Debit/credit cards. Single annual payment of full amount. We will contact you for payment once your application has been processed. Please ensure you have provided your telephone number in section A.

10 10 Dental Care Professionals and Practice Managers Declaration and agreement I hereby apply for DDU membership of The Medical Defence Union Limited (the MDU), in accordance with its Memorandum and Articles of Association. I understand and acknowledge that The Dental Defence Union is the specialist dental division of The Medical Defence Union Limited and references to the DDU and membership of the DDU mean the MDU and membership of the MDU; MDU Services Limited (MDUSL) is the service company for the MDU and DDU and any notices or information which I am required to give to the MDU or DDU should be sent to MDUSL; benefits of membership of the DDU are discretionary and are subject to the MDU s Memorandum and Articles of Association; benefits may be granted to me only as long as I comply with the laws on registration and licensing in force in any country where I practise or engage in postgraduate study; removal from a professional register (even if voluntary) or any change in registration should be notified to the DDU as this will affect membership; with the exception of Good Samaritan acts, the benefits of membership do not extend to any practice undertaken in the USA or Canada or any litigation which may arise in these countries or in the territories and principal island groups under their sovereignty. Restrictions also apply for other countries; I must notify the DDU in writing of any change in address, country or practice or any other circumstance which may be relevant to membership; a condition of membership of the DDU is that any misrepresentation or misstatement in, or omission of, any information which is likely to influence the acceptance or assessment of this application, whether intentional or not, is cause for immediate rejection of this application or termination of membership and that in such circumstances all benefits of membership of the DDU may be withdrawn or denied. I declare that to the best of my knowledge and belief the information provided in connection with this application, whether in my own hand or not, is true and I have not withheld any material facts. Third party reimbursements I understand and acknowledge that, should a third party pay my membership subscription on my behalf, any reimbursement of that subscription will be returned to that third party unless I notify you in writing to the contrary. Data protection ote: The DDU s privacy policy, which can be found on the DDU website at theddu.com/privacy sets out: that the DDU, MDU, MDUSL and other Permitted Users will keep and use your personal information; the purposes for which your personal information will be used and what the DDU/MDU and MDUSL can send to you, including marketing communications. Please read the privacy policy carefully as your signature of the declaration on page 3 of this application is your consent to the way in which your personal data may be used. Marketing communications The DDU will send you materials it thinks will be of interest to you. ou can choose OT to receive these by ticking below or, at any time in the future, updating your preferences on the DDU website at theddu.com. ou may also write to the membership department at One Canada Square, London E14 5GS or membership@theddu.com I do OT wish to receive: the DDU Journal or similar publications communications, including dento-legal updates other direct marketing communications about similar products and services. Statutory communications I agree to: having access to the MDU s annual accounts, directors report and auditor s report, and any other documents or information sent or supplied by the MDU, on the MDU website at themdu.com; notice of general meetings of the MDU being given to me by access on the MDU website, together with details of any proxy appointment deadlines; being notified by electronic mail of the publication or availability of notice of general meetings, or any other documents or information sent or supplied by the MDU, on the MDU website, the address of the website, the place on the website where the documents or information may be accessed and how the documents or information may be accessed; being sent or supplied by the MDU with notice of general meetings or any documents or information, by electronic mail; notify the DDU of my address, which may be used for sending electronic mail for the above purposes. Any address given by me elsewhere on this form is the relevant address for this purpose, until I notify any change. I understand that if the DDU does not have my address, I will receive notification by post instead of electronically; notify the DDU of changes in my address. Further information on electronic communication and statutory information, including any system requirements, is available at themdu.com/agm. If you wish to receive statutory communications by post instead of electronically, please tick here

11 Dental Care Professionals and Practice Managers 11 Before returning this form to us check you have: completed each relevant section completed your payment choice signed the statement on page 3 3 Return the completed form to: FREEPOST MDU SERVICES LIMITED.

12 How to contact us Membership t e membership@theddu.com Advisory t e advisory@theddu.com our feedback Give us your feedback about the DDU theddu.com/feedback Website Have you got our app? The Dental Defence Union (DDU) is the specialist dental division of The Medical Defence Union Limited (MDU) and references to the DDU and DDU membership mean the MDU and membership of the MDU. MDU Services Limited (MDUSL) is authorised and regulated by the Financial Conduct Authority for insurance mediation and consumer credit activities only. MDUSL is an agent for The Medical Defence Union Limited (MDU). MDU is not an insurance company. The benefits of MDU membership are all discretionary and are subject to the Memorandum and Articles of Association. MDU Services Limited, registered in England Registered Office: One Canada Square, London E14 5GS GDP Application form dcp